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HomeMy WebLinkAbout1236A 1770A 1771A (6) i __ _. __. __ _.. __._.._._ _. .-- -... . .. .. . ... _ . :: _:. . .__ _ ___ .. . WORKERS'COMPENSATION DECLARATION � � ����=�� �� � � � � - � . .� . . . � � ..._._._ . , " I hereby offirm tho�I hove a certificate of�o�,e�„o.se�f - � APPLICATION� FOR�.BUILDING �PERMIT � � �� insure,or a cerhficale of Workers'Compensation Insurance, .._ .._.._ ._ . . .. . .__ ..__ . _ .. . , . or a ce�tified copy thereof(Sec:3800,Lab.C.) ' COUNTY OF LOS ANGELES BUILDING AND SAFE Policy No. � � � � Company� � � . - � .. � Cerniied copy is hereby furnished. ' � FOR APPLICANT TO FILL IN q�RE�L63.O �R�f} �D, ' �- Certified topy is filed with ihe muNy 6uilding�inipec- �-� � gUILDING �Zp �R�R �,�N � ,�n T •I p �'�G C , tion depahmeM. ' ADORE55� I�' L���f�0 N� B�i. ef}• � .. ,, ., .. .� . . . ,.,�;' . - .,t .. .... .. . __. .. ...__._ .__. __ . _ Date ' �Applicanl �� �ITV /Rrna�f7 BA� ZIP �� �� LOGAUTY � � ' � CERTIFICP.TE OF EXEMPTION FROM WORKERS'��- '� " --� "" �"� --'-- � � -� '� NO OF BLDGS:-�3��- � NEAREST - 7� � ,. SIZE OF lOT ��b� S NOW ON lOT ' S5 Si. �`' I���R��.� . ..... . .�.. .. _._ ._ .. - � � � � COMPENSATION INSURANCE � • (This iection need not ba completed if Ihe permit is for one � - ianCT-- �- �� �� BIOCK ��- -�� LOT NO. '..... �..._..� ,Nqp gppK' - ' . .. . . pqGE�� " hundred dollars(5100)or less.� �� ._..__ .. '` PAR�� C"'" - A�'�AN TEL U5E ZONE �P . V , - 33 'r I,cerlify that In tha performonce of iha work for whicb this � � owNert ^ NO. 3 ' � 3 ,y�� NO. . � , �'' permit is issued.I shall nof employ any person in any manner ADDRESS j---/Y�CN ��L'�'�S-J- `�...'_ `�ECIAL,.... ..-._ ..-'- � -�-- �-- -� a � "- ' ��'' ' - ppNDITIONS .2 �u so as fo become wb�ect to the Workeri Compenwtlon La s �/ �/^ �� • .� . ��. ' . � �. � .. .� .. � CRY ACI��(/DA_ /'I4TS_ N�ZIP . 17 . .', - ' .p.,l'.. _._'. :._.._. .. . : .... .. .. 'R' Date .�� �. - 'Applitanl � . .' � . . �._.. �� � `� v NOTICE TO APPtICANT: If, ofter making ihis Cerlifimle of /+RCHITER OR TE�� _DISTRICT.. GROUP TYPE � ___._ �_FlR PBOCEqSEO BY .;� ENGINE[R NO. CONST' Z '/�����(� Exemption; you should become�sub�ett�to�the Workers -""�' -� B � - � .�(��".'lJ�� \..4W. Campensation provisions of�he lobor Code;you must forth- nooReSS � - �� with tomply.with suth provisionz or this permil sholl 6e � -- - ,f� . , y deemed revoked. � � - '� CONTRACTOR f\ NO. i TION , . APT. CON00. � �Z ;. .,,,. TEL. STAT�IST�IUL IXASSI�FI�G .. ..-.. . . . . _ . ..:� UCENSED CONTRACTORS DECLARA710N � � �� � - ��:-�� --� - ------ �-----LiC.-� �I r`� DWELL UNITS I hereby alfirm thpt I am licensed under provisions of Chopter 9 ADDRE55 n10. � , . (tommencing wirh Section 7000)of Division 3 of the Busineuand .. . ... . .. ._�i�,- � ' �''�R�'P � � ... . _.. ...----.. ._. .. .___... :. nd my license-is in foil forca ond eNeU. Cirv � � cu55 � �- :- BK --� -� ��- �-- --�"" YAUDATION- � - � � ��- � � " SQ.F7. NO.OF }. ., NO.OF CHECK ; ' �� �� � SIZE- STORIES FAMIlIES ONE �� . '-•..' ',-=�� 2.�.L n � LI ense Number o' " Lic.Class ' �� � � .. . � .. . _ .VALUATION. . _ -.� .'' - _ . ... Contra[tof.. .. . � . . .. �. .Data '. . ..' . .. DESCRIPTION OF WORK'-- ....... AO. .� . s �.. � k • .� �2�. �I am eaempt under Sec. . .. . .- �0?� �0 Uf"�-�jY1�. _ . ... .. .� '. ... _.. � °.2 l�� ' . . . . ' . .. L{� 9 RC' S I �OO IV1 ALTER s � : 6.8P.C.for Ihis reason � RE�AIR (n/ � "- "�- "- • "G 7 V�'c'� ' _ .. . . . _ .. USEOF 1 CG-�l_.1 ❑ /� ��� ._ � � �L-2�5 I ..Dafe: E%ISTING BIDG. DEMOL ❑ '_ . . _ Signafure . - . . _.- ..' '. APPLPe�NiT I� `7 /�� � tEL. FINAI C -.�.._ � OWNER-BUIIDER DECLARATION ...._._ ._.... .NO�./ 3 ' . pATE�� ��j V -..- .—.„' - -�� !��.C'i� � 1 hera y offirm Ihat I am exempf from Ihe Contraclor's License �p �2�h�p�lf'r��-f��S''7'O �C/�Mp�f flNA��..,, . , ..„ , - ; ; �� � , � � Law r tha follawing reoson.($etfion 7031 5,Business and ' �" �' ��.. rF • • •�3 ' Pro ssiom Code): -....... ... _._ ..-...... ." .',. , . BY . _._. .,, . . . . suaoiNo ` I = •3 9,8 1 I, as owner of fha proparty, or my employees with ,,, no�kE55 _ , . . ._.._.__ . _ .._ ..:.__. _ ; ... . . ._' woges as�heir sole compensaiion,will do ihe work and , � � � , , ,�7 c3� �� the srructure is not intended or offered for sole(SeUion ��`��Tr �� ' _..-.. 704d,Business and Pwfessions Code).. . _ _ ..--- MowNG ... :... ...... ....._. ____-TEI. -. .._- ._: ,-----.--.. ... ..-._.,. . . -_ -�� -0!� � -<3�. { I,a%owner of Ihe property,am exclusively coMracting CONTRACTOR NO. � . � ❑ .with licensed comradors ro consrruct the project(Sec- . .-.....---.... .---- � --�-�- ��---..�... -_. . . . . .. -- ... - ... . - .:..._ .. . -: . . `� 7 7..� :r�.�__, tion 70d4,Business and Professions Code1. !�oReSS . , � � .. .. . _. REOUIRED_._ . - _.TOTAL SETeA K . � � . �"r•.• • ..• . .�, `-� �-� -CONSTRUCTION LENDING AGENCY-����� sei encK YArsD Hwi'- veOv.iwe �wioiri� -- �- ����� -� �-� - - -� � � � I hereby affirm thof there is a construcfion lending ogency for FRONT � � � �-��� � ihe performonce of the work for which Ihis permit is issued .. . .v.L-- ..- ..-_. .__.._. _._. ... ...___._. . _ ..__ ._. .. _ _._,__. ...._. ',. J.e e R�,'7�__. ' (Sec.3097.Civ.C.). SIDE - ' , . '� � ' s; . ; , � . .. _ .. _... . .. . ..._ _ P.L. - ---�.'. . � 9.7�c� . . _ ..__ . . __ .. ._. . � Lender's Nama �` V� LDM4 Ref.M : O),� �-=.,���-rj 8 . .__ _..._ . ..._. ....._._ _ .. . V.C.FeaS�_ :7.._ ._ PermnFee ' •� .. . ._ .... . . . . .._. = Lender's Address L , ' . � �� - ''" . I certify ihot�hove read this applicotion and siate that the - .. ...__ �'J- � ... issuan�e Fee-_ - .;. .-� .LDMA P/C B : . � � � obove information is correct.I ogree to comply with oll County �,,,,esr9onan Fea � , �.�. � . ordinontes,and State lows relating_to 6uilding construttion, _._ . __ _.. . _ _:_ -.- _. . Totol Fea-- ,-��-� �LDMA Parm.M� � � - • u pnd hereby authorize representatives of this County to enler � � opon the abave-mentioned properry for inspection porposes. ! � _ � -_�_ -__ - - _. __ _ . .. _�_. _ __.... __._.__.. ._..__ � _ ._. ._. . _.. .__. _ . _ � 0..� ���-�"�� SEE REVERSE FOR EXPUNATORY UNGUAGE � O � � Sig ture ot AGPI cant or Agen� ..._. ..._. Da1e.' '.... _'_"'__ '.. .... ._ ._ ._._. . . . ... _ .. ...._"' _'. .. ._. . _ . 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' .. � ...�........... . _uo!padsu��o��adg . . .. .-_ ... � .. ._ __ .,. .___. . , hag)palad eyi I�ni�suo�o�s�opoiwo�pesua�i�yiim 6u�i� �' � -io��uo�A�anisnpYawb'Aliadmday���o�aumoso'I,,❑� . . .� . -.___.. ... ....... ... . ..._...___ ... . ._. _ ... . .�: . . _.. ...... (Aduo7)�a�uai) ,.. , . . . .. �.�. . .. �- '�uoii�aioiduoi�isspad � ..:.�. ; -'�.�,� .�. ... .'(a�asfuarod.tnJaqJ ..... _-_- - ---- �------ --�- -- -- - '. . . -..� . -.: '� ' ---� � ao�onosd�ui�o p�rnq7uu pip oq tvrrt Xurnaad/o uupinq . . ,. �.,� ���: � .� - . . ayp.anaN Ilim�laplmq-lau.no.aqt •uoeja�Jww fo saad',.� . . , ...-.,. . _. �... '.: . �..__ �,.._ . .....-- � I�--:_ . .'---�wi6o�oa<j � aHodrcfppnpforsrtuaruanwd�u?�o8urp�rnqaqp��anamuq�. � . . . . . i , , 'f! '�/vs-�uf pa�affo��to papuaJw �ors asv�sluaivanoid, . . _ . .i • . 6uipoi� . � -mi�rpnr�taq��paprao�d 'saa�Cotdrua uoto srg q8na�y� �' . � . � ,.. . � . . ._. . � .. - �_.. _.._.. .. . . � io fjaswx���om qons saop oqni pun�una�ay7 s�noi�J�bi.ro . .. -. . . -"- --...-'luawliodad en j . tplrmq oqm i(}�ad��d fo saumo uv ol AjJJe tou raop mo7 '' � . ' ., � . . , - �.� . . . . . ...— --�_. ..- . .. . . . . . R� .. ..___ . ._ _ ._._- -..._ ._ ._._ __ ._ _--.'.__.. . ._ ._;__. ... ..��:. _ uaw� da44qoaH . aruam7 rsut�ol�uaj aq_y iapo7 tuurrstaf 1d puv srvu�s . . . � ��o (4uoL om�a Ii o'�P uoi�os adww a'os qa t�so sa6 4,�� � �-� � aa a os�o a�a o�o a ua ui ou s�e�n�n�is a - _ __ .__...._._. . ..---- ..._ _.. .'_- ... _ . . ._ _- --. . , oM„ . . . ._._ _..__ . _ �.� �� ' ' �• �alo�i�ilia)�alo(y� . 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J 9 f1P f Il7d�i�axasivc�jdry7io/a1'o� , . . -- .__. .�... . _._ . suoisrvlo�d pua srauim�aryt fo£uorrp�iQ f°(OOOL uorl ' , �1..�� �..�.��. 1� . - ..� �. ,� +�aq ptpn b'upubruwoaJ(G�'+J°fl�l mn7 arua77 s,�op�oi� . . -. -- . . ._.. __ . --- .. . . � �. . . .. -uo�ayt fo suoesinosdarp ot t�onr�nd p�'sua�r/s�ay�vqt � juaivaTVJt PvuXir o a��/07 ltt[1�JlJ�(�JRS JOf 7uo�ilddc aq+ ' � i� �"1'�i . . • .. � ..., . , ... . .. . . . ___ ... , . .. ._.... . . �� •�. . t�Jircba.torjn'v�uan.rs:rt/a7��(�J'��nl�nitrd"ua�radel�to�-�- �qn�oruap�ano�4un Va71v yonitruw o77(iwaJv sa��nbas ��.. . . .. . . . . ... - . . e1°O �� '�N e7oU 'oN q�iqm d'7uno�io 6}p,tuy.�pb�suarss�fu.iaTuo rsauisnQ . . peeoiddy_. . ^ , (S;lEOL..'�ag) �•uosoa.�6J�,�oj�o;�.eyi.�o} �+oj esuaiij, . .� . �p�uinlay . , , . � !ol s,�opo��uo)ayl wo�y�dwaxa wo��oy�wn��o Aqa�ay� � � � �� � � � ��� NOI,LV2Itl7�il4 NBOII(lfl•NaNMO 5310N S,tl01�9dSN1 . 1Ntl�IlddV Ol SNtlld �